Gender Norms and Structural Barriers to Use of HIV Prevention in Unmarried and Married Young Women in Manicaland, Zimbabwe: An HIV Prevention Cascade Analysis.

Abstract

Background: Gender norms against adolescent girls and young women (AGYW)'s having pre-marital sex and using condoms in marriage are included as barriers to motivation to use condoms in HIV prevention cascades. Representative data on gender norms are needed to test this assumption.

Methods: General-population survey participants in Manicaland, Zimbabwe (ages≥15, N=9803) reported agreement/disagreement with statements on gender norms. AGYW at risk of HIV infection reported whether community views discouraged condom use. Multivariable logistic regression was used to measure associations between AGYW's perceiving negative gender norms and condom HIV prevention cascades.

Results: 57% of men and 70% of women disagreed that 'If I have a teenage daughter and she has sex before marriage, I would be ok with this'; and 41% of men and 57% of women disagreed that 'If I have a teenage daughter, I would tell her about condoms'. 32% and 69% of sexually-active HIV-negative unmarried AGYW, respectively, said negative community views were important in their decisions to use condoms and their friends were not using condoms. In each case, those who agreed had lower motivation to use condoms. Fewer unmarried AGYW with friends not using condoms used condoms themselves (39% vs. 68%; age- and site-adjusted odds ratios (aOR)=0.29, 95%CI, 0.15-0.55). 21% of men and 32.5% of women found condom use in marriage acceptable. 74% and 93% of married AGYW at risk, respectively, said negative community views influenced their decisions to use condoms and their friends did not use condoms. Fewer married AGYW reporting friends not using condoms were motivated to use condoms but no difference was found in their own condom use (4.1% vs. 6.9%; aOR=0.57, 95%CI, 0.08-2.66).

Conclusions: Negative gender norms can form a barrier to motivation to use condoms in unmarried and married AGYW at risk of HIV infection, and, for unmarried AGYW, to condom use.